TR-0452 (Rev. 6/18) - 1 - RDA-2516
1. Account Information
Account Owner: TIPS Account Number
First Name MI Last Name
Telephone Number (dayme)
Designated Beneciary:
First Name MI Last Name
Complete this form to request a withdrawal from your TIPS account.
Your beneciary will not be eligible for a matching grant for contribuons made in the same qualifying
period that a withdrawal is taken from his/her contribuon account.
For payment to you for qualied educaon expenses of the beneciary, provide copies of your receipts
when requesng a withdrawal. For payment directly to the educaonal instuon, a copy of the invoice
from the instuon is required..
If you have any quesons, please contact TIPS at 615-741-1502 or toll-free at 1-855-386-7827, Monday
through Friday, from 8:00 a.m. to 4:30 p.m. (Central Time).
Print clearly in all CAPITAL LETTERS (one leer per box). Please mail or fax this completed form and any
required documents to one of the addresses below. Do not staple.
For Regular Mail For Overnight or Registered Mail
Tennessee Investments Preparing Scholars Tennessee Investments Preparing Scholars
P.O. Box 55597 95 Wells Ave, Suite 155
Boston, MA 02205-5597 Newton, MA 02459-3204
Tennessee Investments Preparing Scholars
A Program of the Tennessee Department of Treasury
P.O. Box 55597 w Boston, MA w 02205-5597
Local: 615-741-1502 w Toll-Free: 1-855-386-7827 w Fax: 615-401-6816
Email: w Website:ps
TR-0452 (Rev. 6/18) - 2 - RDA-2516
2. Withdrawal Information
Enclose copies of your receipts for the beneciarys educaon expenses that you have paid. If you are requesng the
withdrawal be paid directly to an educaonal instuon, please submit a copy of the bill from the instuon. The
amount of the withdrawal cannot exceed the amount stated on the receipts or bill. Please allow 7-10 business days
for receipt of payment.
Amount of Withdrawal
Payable to the Account Owner (You will receive a check at your address on record.)
Payable to the Designated Beneciary (The beneciary will receive a check at his/her address on record.)
Payable to the Educaonal Instuon (Checks are reported under the beneciarys Social Security number.)
Student ID Number (required if payable to an instuon) Due Date (if applicable)
Name of Educaonal Instuon
Department, Oce or Contact Name
Street Address
City State Zip Code
3. Signature
Please sign your name exactly as it appears on your account.
I cerfy that the expenses in the enclosed receipts or invoices are for qualifed higher educaon expenses at an eligible
educaonal instuon.
Account Owners Signature Date